Green Doctor request for support

Are you contacting us for yourself or on behalf of someone else?(Required)
- For myself
- On behalf of someone else

About the person making the referral

Please let us know who is making the referral so we can let you know what action we have been able to take or in case we need more information.
Data protection disclaimer(Required)
The person that I am referring has consented to Groundwork contacting them.
- I have the consent of the person that I am making a referral for to pass their information to Groundwork.
Name of person making the referral(Required)
First Last
Referrer's phone number(Required)
Referrer's email address(Required)
Referrer's organisation (if applicable)
Relationship to the person being referred

For example: landlord, family member, friend, housing officer etc.

About you / the person needing Green Doctor support

Please let us know your contact details / the contact details for the person that we need to contact about Green Doctor support.
Name(Required)
Please let us know your name / the name of the person we need to contact.
First Last
Phone(Required)
Please let us know you / the phone number of the person that we need to contact.
Postcode(Required)
We need your postcode / the postcode of the person that we need to contact so we can pass the message on to the correct local Green Doctor team.

Please enter the full postcode
What region of the UK do you / the person we need to contact live in?(Required)
This allows us to direct your query on to the correct regional team.
Green Doctor is unavailable in Scotland

Unfortunately Green Doctor does not currently operate in Scotland.
Email
Please let us know the email address of the person that we need to contact (if applicable)

About your data

Information that you submit in this form will be collected by Groundwork UK and shared with local Groundwork Trusts so that they can respond to your query. It will not be used for any other purpose.
Data protection agreement(Required)
- I agree to Groundwork processing my information for the purposes outlined above.
Comments
This field is for validation purposes and should be left unchanged.